HCDM 33 | Misconceptions About Nephrology

 

A number of people suffer from kidney failure. They struggle with flushing out the toxins that the body generates through the course of living. Rick Hayashi, MD is the expert at helping these people. As a Nephrologist, Rick specializes in taking care of patients with all spectrums of kidney disease. He joins host Richard Marn, MD, to help us understand the scope of the profession while also guiding us into his own journey and experiences in this career. Seeing how there is a downward trend in the interest towards nephrology Rick breaks down the misconceptions people have about nephrologists and shares the rewarding parts of being one. Not many dream of going to a medical school to become a nephrologist. Yet, when you look deeper, it is undeniably responsible for saving millions of lives. Join Rick and Richard in this episode to gain a clearer understanding of this “unsexy” job and see more than what meets the eye.

Listen to the podcast here:

Breaking Down Misconceptions About Nephrology

With Nephrologist – Rick Hayashi, MD

In this episode, we’re going to talk with a physician who would describe his profession as not very sexy. However, it will be very clear that his profession helps thousands, if not millions of lives every year. As a profession, they also connect with their patients because they see these patients on a regular basis. My guest is a nephrologist, a kidney specialist working in Honolulu, Hawaii. His name is Dr. Rick Hayashi. One thing about Dr. Hayashi that most of you don’t know is he is one of my best friends from medical school. I will tell you, before we go into his bio, that Rick is one of those friends where I consider it an honor to be his friend. He is intelligent, smart, hardworking, kind, humble and available when I need him, when I want to talk to him. It also helps that he has a wonderful wife and family.

I feel honored that we’ve been able to know each other and grow together as our families have gotten to know each other as well. Here’s a quick bio on Rick. He was born and raised in Maui. He went to college at University of Hawaii, then got his medical degree at the University of Hawaii, along with yours truly. He then went to UCLA for internship and residency, as well as did a chief residency year in internal medicine.

At UCLA, he also did his nephrology fellowship, then did a kidney transplant fellowship at SUNY Brooklyn Medical Center. He worked at the VA Medical Center in Hawaii and the Pacific Islands for several years until finally moving to private practice in Honolulu, Hawaii. Rick has won a number of accolades and awards over the years, but one that stands out to me is he won the Po’okela No’eau Award chosen by the University of Hawaii School of Medicine, Class of 2000, as the most ideal graduating physician. In some way, that says a lot about Rick right there. Without much further ado, let’s jump into this conversation with Dr. Rick Hayashi.

How are you doing, Rick? Thanks for joining me on this episode.

I’m glad to be a part of it. It’s a privilege to be asked to do this with you.

Thanks a lot. I appreciate it. Let’s dive into it because I don’t want to pull you away too long from your patient care. Let’s dive into this and hopefully, you can share some of your stories. First, I want to talk about if you could tell me what your profession is, what you do, and what type of patients you take care of.

I’m a board-certified nephrologist. After we graduated medical school together, I did a residency in internal medicine and then following internal medicine, I did a fellowship in nephrology, which is the study of kidney disease. Following that, I did another fellowship in kidney transplant. I take care of adult patients with all spectrums of kidney disease, including kidney failure, patients who have had kidney transplants, complicated patients with hypertension, electrolyte disorders, acid-based disorders. That’s what I do.

How exactly do you help them?

It depends what problems they come to me with. Majority of my patients are patients who have chronic kidney disease of various stages. I help them by trying to figure out why they have chronic kidney disease. I try to slow down the progression of their chronic kidney disease by treating the underlying reasons for their chronic kidney disease. In the unfortunate ones, I’m preparing them for dialysis and/or kidney transplantation.

Are you ever doing procedures on patients?

I’m not a surgeon. I’m a medical doctor. Putting in temporary dialysis catheters and then also kidney biopsy, those are the two procedures that I do. I do oversee a procedure called dialysis. I don’t do the dialysis, but it is technically a procedure that I am responsible for that a lot of my patients undergo.

You determine how the dialysis should run?

I adjust the dialysis to each individual patient’s specific needs. No dialysis prescription is equivalent. It has to be adjusted. It’s continuously adjusted on a month-to-month basis based on what their labs show, what their vitals are, and their physical examination are.

In what settings are you taking care of patients? Is it always in a hospital, other type of facilities?

The nice thing about nephrology, some people might view it as a strength, others as a weakness. We’re like the old-time physicians, but it’s so compartmentalized. You have physicians who are only in the hospital or physicians who are only in the clinic. Whereas I see patients in the hospital, in the intensive care unit, in the clinic, in the dialysis unit, all over the place. I see patients who I’ve taken care of for many years. I see them when they’re admitted to the hospital. I see patients in all realms.

Dialysis is a mechanical way to remove urine from the blood. Click To Tweet

You often take care of patients over many months, sometimes years, not just for a day.

No, many years. From the time that they’re referred to me all the way to until they pass or their entire life.

You have sometimes a long-term relationship with these patients not only medically but personally as well.

I get to know a lot of them. Over the course of many years, we share family stories. Their family members come in and I get to meet them. I get to meet the whole family a lot of times. A lot of these patients are very sick too. They’re in the hospital and their family comes in. We get pretty close.

That’s a lot different than me because as anesthesiologist, I take care of one patient for a day. I usually don’t see them until they come back for surgery, if at all. All I do is work in an operating room setting as for most anesthesiologists. It’s very different than what you’re doing where you see patients regularly weekly, if not several times a week.

Anesthesia is innate to that specialty. That’s how it was many years ago. Whereas with internal medicine, in the past, internists would see their patients in clinic. When they got admitted, they would follow them into the hospital. Nowadays, everything is compartmentalized. In internal medicine, for example, an outpatient internist will only see them in the outpatient, when they’re admitted and they get admitted to a hospitalist. The outpatient doctor has nothing to do with their inpatient care. There’s a big fragmentation in care. Whereas for me, I’m pretty much one of the only ones that sees them through the entire course, whether they’re inpatient or outpatient. I have a better understanding of the whole picture of what’s going on with their medical care. The fragmentation has done for quality-of-life reasons. Nephrology quality of life is fairly challenging at times because of that.

A lot of nephrologists also are like you in terms of they’re taking care of patients in the hospital, in the dialysis unit, and the clinic. Do all nephrologists behave that way or some nephrologists only work in hospital or only work in dialysis unit?

There’s a mixture. Here in Hawaii, for example, here at Queens, there are a couple of nephrologists that only see patients in the hospital. They’re hospital nephrologists. They don’t accept outpatient referrals. All their new consults are from the hospital. They’ll follow up with them when they’re discharged in the clinic, but they’re not accepting any new outpatient referrals. It’s all inpatient based.

For your specialty, it’s inherent in your job that you constantly and regularly have to look at the patient’s labs. That’s a regular part of care of the patient.

The labs are important, but everything is important, the I’s and O’s, the daily weights, the hemodynamics, pressure trends, how much Levophed they’re on. Especially in my ICU patients who are on continuous dialysis, they’re critically ill. I look at everything because the continuous dialysis that I’m running, we have control over all those parameters. We have control over the acid base status, the electrolytes, the volume status, the fluid removal. We have to pay attention to all of those things.

Some of the readers are high school students or college students. Can you describe in brief what dialysis is?

People pee, it’s a way to urinate. That’s the body’s way of removing excess fluid, poisons and toxins that our body generates through the course of living. Patients who have kidney failure, they’re not able to clean their blood of the urine. What dialysis is for patients who are in kidney failure, it’s a mechanical way to remove urine from the blood essentially.

Is there anybody else that does dialysis or is it only nephrologist?

It’s only nephrologist. You have to have board certification in nephrology or board eligibility in nephrology to be credentialed to do dialysis with the hospitals. Otherwise, you can’t perform dialysis.

It’s a unique skillset just for your profession. What is a typical day like for you, start to finish?

HCDM 33 | Misconceptions About Nephrology

Misconceptions About Nephrology: The fragmentation has been done for quality-of-life reasons. Nephrology quality of life is fairly challenging at times because of that.

 

It varies day-to-day, depending if I have clinic or not on that particular day. For example, now I don’t have clinic. I have to round in the hospital and I can do this interview. Whereas the day before, I got in at 6:00 and started rounding. I rounded up until about 11:30, and then I rushed over to my office for 12:00 outpatient clinic where I saw outpatients until 5:00.

When you’re in the clinic for the afternoon, how many patients are you seeing usually?

In a half day, I’ll see anywhere from 15 to 20 patients.

Usually, your day ends at 5:00 or what happens after that?

It depends if I’m on call. I’m in a group and we rotate call by the week. If I’m on call that week, my day doesn’t end. I have the pager. I get paged through the night for any issues that come up with any of our patients from all the hospitals, all the dialysis units, the outpatient setting. It can be busy for that week when I’m on call. When I’m off call, I do my regular day, but then at 5:00, I can turn my pager off.

When you’re on call, you are fielding calls from nurses or the patients themselves about any issues. You try to help manage it whether it’s a dialysis or kidney related problems.

From all the hospitals too, so from the hospital emergency rooms at Queens, Straub and Pali Momi, all the local hospitals.

What misconceptions do people have about your career?

Nationwide there is a shortage of nephrologists. Nephrology has a big image problem. I always joke that nobody ever goes to medical school dreaming of becoming a nephrologist. I sure didn’t. It’s not one of those glamorous, sexy specialties like anesthesiology. Medical students go into medical school dreaming of becoming that, cardiology, brain surgeon, or anything like that. Nobody goes to medical school dreaming of being a nephrologist. I teach at the medical school. I teach first-year medical students Basic Nephrology. I do a lecture and I do CSP, which is a Clinical Skills Preceptorship at the University of Hawaii.

The very first question I ask the entire class, “How many of you want to be nephrologists?” and universally, nobody raises their hand. I ask, “How many of you want to be surgeons or neurosurgeons?” You get a mix, but more people or at least some people raise their hand. There’s an image issue with this specialty. You’re dealing with urine. It’s complicated. It’s mentally demanding because the physiology can be complex. The patients are sick. A lot of multi-system organ dysfunction. It all impacts the kidney.

Because of all those reasons, people are not going into nephrology. It’s very easy to get a nephrology fellowship now. A lot of prestigious programs are not filling. The number of patients with kidney disease is growing exponentially. In Hawaii, we have a population of over one million. There are about 145,000 people who have chronic kidney disease. How many nephrologists do we have on the island? I’m guessing 10, 15 nephrologists on the island, maybe more, I haven’t counted. For 145,000 patients, there are clearly not enough nephrologists. There might be twenty nephrologists.

Your work is mentally demanding. You’re busy because of the sheer numbers of patients and a low number of nephrologists to those patients.

The acuity of the patients is complex. They take time to think through all the issues especially as it relates to the kidneys.

Given that, what is the rewarding part of being a nephrologist?

There are more opportunities to supplement your income if you're in private practice. Click To Tweet

It’s the continuity of care and seeing patients in the clinic through their hospitalizations. A lot of times, it’s multiple hospitalizations. I have the feeling that I’m not there for one episode of their care, I’m there throughout. The patients come to see me as somebody very important in their care. That was the whole reason I wanted to go into medicine. I didn’t go into medicine thinking I was going to be a nephrologist. I wanted to go into medicine to take care of people and to be with them during the hard times, to be with them and to take care of them. That’s very rewarding. A lot of these patients are almost like family because I see them so often. You get attached to them. I liked that. There’s a downside to that too because it it’s very taxing and draining physically and emotionally sometimes.

I can imagine. How would you describe your work-life balance as a nephrologist?

I’m in a group, so we share call, we share space, we cover each other’s patients. It does help with work-life balance. My father-in-law was a nephrologist and he was in solo practice. He didn’t cover as many patients because he only had his patient panel. Whereas when I’m on call, I’m covering the panel of six busy nephrologists, but he never had any time off. He was always on call. I can turn my pager off when I’m not on call at 5:00 PM. It does allow me to have dinner with my family and to be able to enjoy my family. It’s the call weeks that are more challenging.

When you’re seeing patients as a nephrologist, how many times are you seeing them a week?

My hospitalized patients, I see them every day. The patients that are on chronic dialysis, I have nurse practitioners who see them weekly in the dialysis unit on dialysis. Depending on what active issues are going on, a lot of these chronic dialysis patients are very stable. They’re already inundated with their dialysis appointments, cardiology, and all these other appointments. I don’t want to see them unnecessarily, but it can vary maybe once every couple of weeks to once every 3 to 6 months.

When someone’s on dialysis, don’t you have to get dialysis 2, 3 times a week? Don’t you have to see them therefore every 2 to 3 times a week as well or your nurse practitioners are able to help to do that?

Even the nurse practitioners only need to see them once a week even though they’re dialyzing three times a week. For the most part, it’s pretty stable. There are usually no issues. If there are, we have to be available. I get called or my nurse practitioner gets called, if the blood pressure drops, patient cramps, patient codes on dialysis. We get called and we have to be able to handle those issues like if there’s an infection or whatever it may be.

You talked about how the interest in nephrology as a profession has gone down. Such that finding a position in nephrology after medical school is easier than in the past. What do you think the future outlook is like for your profession? Is it a profession that will always be needed?

As long as America is dealing with obesity epidemic and diabetes, there’s always going to be a need for nephrologists. As the nephrology workforce ages and retires, and there’s not enough trainees filling those spots, there’s going to be an increased demand for nephrologists. The job outlook is good for nephrologists. Nobody seems to be interested in going into nephrology, but that’s part of the reason the job outlook is so good.

If you do recommend this career to students, what students do you think best flourish in this profession?

You work hard, so it has to be somebody who wants to do it for the right reasons, who has an old-school view of medicine where their doctor follows the patient through thick and thin, through hospitalization, through outpatient. Somebody who holds on to those ideals of medicine, those kinds of people would be perfect for nephrology. You can make more money in other specialties. You can make twice as much money as a cardiologist. It takes a special person.

Nephrology can be very lucrative from a financial standpoint.

Potentially, it can be but not always. It depends how hard you work. If you’re employed as a nephrologist by Kaiser or the VA or by a healthcare system, you’re not going to make too much. You’ll make maybe a little more than what a hospitalist would make. That’s having done several years of fellowship. You could not do fellowship and be a hospitalist, and make almost as much as an employed nephrologist would make. When you’re in private practice though, you have other opportunities. You have opportunities to buy into like dialysis units. There are more opportunities to supplement your income if you’re in private practice.

I want to talk a little bit about how you even got into this, but before we do that, can you tell me what you were like as a high school student? Were you someone that was always interested in going to medicine?

HCDM 33 | Misconceptions About Nephrology

Misconceptions About Nephrology: Nobody ever goes to medical school dreaming of becoming a nephrologist.

 

I originally wanted to either be a History teacher or go to law school. That’s what I thought I was going to do.

It’s different than what you’re doing now.

I didn’t know what I was going to do. I wasn’t serious about those things. I didn’t think medicine, but I think in the back of my mind, I have a cousin who’s nine years older than me who went to medical school, who I idolized growing up. He went to ‘Iolani, this very prestigious private school. I went to a public school on the Island of Maui. It’s very different pedigrees. I didn’t think I had what it took to make it to medical school. Not that I didn’t want to become a doctor. I just didn’t think it was even within the realm of possibility.

When did the idea of going into medicine pop in your mind?

I went to University of Hawaii. I wanted to go away, but my mother being a single mom, she couldn’t afford to send me away. I got accepted to several colleges, but I had to go to University of Hawaii, which I enjoyed. I had a good time there. In my first year there, I got a 4.0 to a couple of science classes. I was like, “Maybe I can go into medicine.” It was between my first and second year as an undergraduate at the University of Hawaii where I was like, “Let me try this.” I took more science classes and then I enrolled in this Howard Hughes Medical Research Program. I was able to do some intensive research published, presented nationally at a Cancer Society Symposium. I did pretty well grades-wise. I took the MCAT and got into JABSOM. We started med school together in 1996.

JABSOM, for people who are reading is the acronym for Johnny A. Burns School of Medicine at University of Hawaii. Because you were getting positive feedback in terms of your grades, that filled the idea that, “I can get into medical school.”

The acceptance rates were very low. Our starting class size was 55 over 1,000 applicants. The sheer odds were not favorable.

What was your backup plan?

Reapply, I didn’t have enough backup plan. At that point, it was all or nothing.

What was your degree in?

UH offers this program called Liberal Studies where you can design your own degree. I knew I wanted to go to med school in Hawaii. I knew I wanted to be here serving the population here. I combined a degree with Hawaiian Language and Biomedical Science. I created a degree. I took advanced level Hawaiian Language courses as well as other pre-med requisites, and then some higher-level science courses like some molecular and advance biochemistry. I created my own degree.

What was the name of your degree?

Healthcare in Hawaii, something like that. I had to get it approved. You have to write an essay as to why your degree should be approved. It had to be approved by some academic counselors. It was approved.

I was impressed because when we were in medical school, you could speak fluent Hawaiian, which at the time was a dying language. Lately, it started to flourish over the last few decades, not only for its culture, but also the language and the history of Hawaiiana. First of all, I was always impressed because you took on this language and learned it. Because you did this specialty degree, did that help you get into medical school because it’s very unique and stood out?

Care about what you do and care about people, and good things will happen. Click To Tweet

It did but I didn’t do it for that reason. I did it because I’ve always loved Hawaiian language even growing up on Maui. I remember going over to a friend’s house. This is back in the early ‘80s, late ‘70s and hearing the grandparents speak Hawaiian. Even from a young age, I was always drawn to that. Throughout middle school and high school, I was always involved in the Hawaiian club. We would tour as a school. We went to Lanai, Molokai. We would sing songs and do demonstrations. I was the only non-Hawaiian. I’m Japanese and a little bit of Chinese. I’ve always been enthralled by the culture and the language. From a very young age, I love the Hawaiian language.

Even to this day, I still love it. I still read and listen to Hawaiian language radio. I speak to whoever I can. I do think it was something different. It was something that made you stand out because everybody who applies to medical school has outstanding grades. They have good MCAT scores. They’ve done some research, some community service or volunteer work, but then that’s everybody. That becomes the norm. When you’re applying to medical school, you do need something to differentiate you. That’s maybe what differentiated me. I was able to publish and research, but yet I was able to focus on the humanities, the language, and some of the unique issues that affect native Hawaiians and the native Hawaiian healthcare.

That’s made you stand out in my mind. It’s awesome to hear when you do speak something in the Hawaiian language. Reflecting back, what would you have done differently if anything?

I look back at what we went through in medical school. Those four years in medical school with you, Richard and with some of our other friends were some of the best years of my life. It was fun. I think back, the time studying after midnight at that internet cafe or Barnes & Nobles, Starbucks, but also some of the trips we took. I don’t think I would have changed anything. I’ve been blessed. My life has been blessed. My medical career, my training, everything has been wonderful. I wouldn’t have changed anything.

Regarding your training, after medical school, you went on to do an internship in internal medicine and nephrology. That’s a total of seven years after medical school?

After I graduated in medical school, I was in training for an additional seven years. I did four years of internal medicine because I did a chief residency here. I did a two year in nephrology fellowship, and then third year in transplant.

Of all those specialties and all that training you went to, what was the hardest part?

Most people who go through training, intern year is the hardest. We were interns in 2000, 2001, a couple of years before they instituted any of the work regulations that they’re protected by now. I took Q3 call every third night in the ICU. You don’t sleep at all. I know some surgical residents were taking Q2 call, where every other night, you’re up all night. You might have experienced that. I remember not sleeping for 36 hours sometimes, working all day, all night, all day the next day, and then coming home at 11:00 the next night, not having slept a single minute. That was brutal. That was physically and psychologically brutal. That’s not allowed anymore. Back in the day, there were no holds barred. They would work you to the bone in internship.

I want to shift gears a little bit. I want to turn our attention to what I call Dr. Marn’s Lightning Round. You give your best answer. It doesn’t need to be long unless you wanted to. Favorite city in the United States besides the one you live in?

New York City, your hometown.

In a scale of 1 to 10, how good of a driver are you?

I’m 8.5. I’ve not gotten into a major accident.

You’re giving yourself a half point.

Sometimes I struggle a little bit in parallel parking. If not for the parallel parking issue, maybe 9.5.

HCDM 33 | Misconceptions About Nephrology

Misconceptions About Nephrology: As long as America is dealing with the obesity epidemic and diabetes, there’s always going to be a need for nephrologists.

 

What’s your ideal outside temperature?

It’s 75 degrees.

If you were stuck on an island and could bring only two things with you, what would you bring?

My phone because that would provide you a lot of information and communication, and my computer.

If you were 80 years old, what would you tell your children about life and about business that would be the most important thing for them to know to get a head start?

Do things as well, work hard, do your best, show that you care, care about what you do, care about people and then good things will happen if you do that.

What’s your best childhood memory?

I would say growing up in Maui and the freedom. When I was in middle school, I had a bike. I remember I would leave at 7:00 in the morning with my friends and not come home until 7:00 at night. My mom had no idea where I was and we would go everywhere. I had $5 in my pocket. I would buy lunch with that and drinks. We would go play in the ditch, ride our bikes up to EO Valley, and go everywhere. The freedom of doing that helped to shape who I am now.

It’s different than how our kids are growing up to now. Where can readers go to reach you and learn more about you?

We do have a website. You can google, Hawaii Kidney Specialists. That’s the name of my nephrology group. On that, we have contact information. We have bios of all the physicians, including myself, and pictures, so you can see who my partners are. That’s probably the best way to get in touch with me. I’m not on Facebook or Instagram. It would be tough. It’s so busy. I don’t know if I could devote the time to maintain any presence there.

Thanks a lot for joining me. I appreciate it.

Richard, it’s good to hear from you as always.

Everybody, that’s our show. Thanks for tuning in. To learn more about our guest or other past guests, check out my website, HealthCareersWithDrMarn.com or HCWithDrMarn.com. If you like what you read, then please go to my website, add your name and email to my email list. That way you can get the latest announcements and news as they arise. You can also find me on Instagram, @DrRichardMarn. Thank you so much for reading. I’ll catch you on the next episode.

 Important Links:

About Rick Hayashi, MD

HCDM 33 | Misconceptions About NephrologyDr. Rick Hayashi joined the practice in 2016 after serving as a Staff Nephrologist for Veterans Affairs Pacific Islands and a Hospitalist at Queens Medical Center West. In 2000, he completed his medical degree at the University of Hawaii John A. Burns School of Medicine (JABSOM), followed by his residency and nephrology fellowship at UCLA Medical Center, where he also served as Chief Medical Resident. Additionally, Dr. Rick Hayashi completed his Renal Transplant Fellowship at State University of New York (SUNY) in 2007.

Heavily committed to education, Dr. Hayashi has been involved in several academic/research projects and publications through JABSOM, University of California – Los Angeles (UCLA), and Cedars- Sinai Medical Center. Currently, Dr. Hayashi serves as Assistant Clinical Professor of Medicine at JABSOM. He is board-certified with the American Board of Internal Medicine and the American Board of Nephrology. Dr. Hayashi is the Medical Director of US Renal Care West Oahu dialysis clinic.